Medication Errors in a Pediatric Intensive Care Unit: Incidence, Types and Outcome

Medication errors (mes) play a significant role in mortality and morbidity of hospitalized patients. therefore, it seems advisable to determine types and consequences of such errors when addressing patient safety. the aim of this study was to determine the incidence, types and outcomes of errors, in a 10 bed pediatric intensive care unit at a large teaching hospital from september 2013 to february 2014 in shiraz, southern iran.the occurrence of errors was detected with the direct observation method. a trained pharmacist selected 41 patients randomly in 41 working shifts. none of the patients were included in the study twice. in each shift, patient’s medications were observed for prescription, administration, transcription, and dispensing. the pharmacist would intervene only if the me could cause substantial harm to a patient. all data were reviewed by a clinical pharmacist and a pediatric intensivist to confirm the type of errors. of the 512 drug dosages observed, 48.8 errors/100 orders were detected. administration errors occurred on 148 occasions, with 28.9 chances to occur in each 100 orders. prescription, transcription and dispensing errors came next with 14.25, 4.88 and 0.78 chances in each 100 orders, respectively. wrong time, technique, and preparation were among the most common types of administration errors with the frequency of 14.1%, 5.7%, and 4.9%, respectively. the group of errors known as monitoring errors, was the most common type of prescribtion error, with a frequency of 11.3%. the results of this study highlight the high rate of medication errors in the pediatric icu that was studied, with administration and prescription errors marking the highest share of them. hence implementing effective strategies to reduce these errors, are crucially needed.